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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY>PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> UMIT EXPIRES YEAR FROM DATE <br /> (Complete in Triplicate) ` <br /> Application is hereby made,to San Joaquin County for a permit to construct and/or inatall the work herein described. This <br /> aPPlication is made in compliance with San Joaquin County Ordinance No, 549and 1862 and the Rules and Regulations of Sen <br /> i Joaquin County Public Health Services. <br /> Job Address City 7 Lot Size/Acreage <br /> Owner's Nameg42 Address G� L <br /> -- LPhone <br /> 4 1 <br /> Contractor. Address License No� Phone <br /> TYPE OF WELL(PUMP, _ � NEW WELL 0 WELL REPLACEMENT-77 DESTRUCTION 0 Out of Service Well <br /> i PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHER 0 Monitoring Well <br /> i � .. <br /> i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE <br /> I <br /> FOUNDATION AGRICULTURE WELL OTHER WELT. PITS/SUMPS _ <br /> 'INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 17 Industrial © Open Bottom „❑ Manteca` Dia. of Well Excavation Dia. of Well Casing' <br /> f Y; <br /> 1.) Domestic/Private. _0 Gravel Pack 0 Tracy Type of Casing Specifications f <br /> 1'.1 Public I-] Other -'(l'Delta Depth of Grout Seal Type of Grout <br /> s <br /> ., o. •. <br /> I I Irrigation ', ° bw`` <br /> g Apprax, Depth I I t astern `Surface Seal Installed by <br /> Repair Work Done U Type at Pum ~ <br /> p H.P. State Work Done_ <br /> Well Destruction CI Well Diameter .Sealing Material & Depth <br /> 4 � <br /> s f.. Depth `' Filler'Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I } REPAIR/ADDITIONDESTRUCTION I i (No septic system permitted if public sewgr is (� <br /> 3 available within 200 feet.) /� + <br /> ' Installation will serve:.-Residence Commercial_ Other a <br /> f Number of living units: 4— Number of bedrooms _ <br /> Character of soil to-a depth o[3-feet: _ Water table depth <br /> SEPTIC TANK - O Type/Mfg LCapacky 4Ao. Compartments <br /> PKG. TREATMENT PLT, ❑ ` �� Method of Disposal <br /> Distance to nearest: Well ` Foundation ,property Line <br /> ( LEACHING LINE ` No. & Length of lines Total length/size ' <br /> a FILTER BED 0 Distance to nearest: Well <br /> Foundation Ldp property Line , ` <br /> 7 <br /> SEEPAGE PITS 11 Depth _ � SiZe � Number <br /> r SUMPS LI: Distance to nearest: Well ` ,Foun8a'libn 43:),—^ property Line—92- <br /> DISPOSALPONDS <br /> I hereby certify that.I have prepared this applipation and that the work will be done in accordance with San Joaquin county ordinances, state taws, and <br /> rules and'regulations of the San Joaquin County" <br /> - <br /> a Hame owner or licensed agents signature certifies the followings ;i certify that in the perfarmaii a of the work for which this permit is issued, I shall not <br /> j employ any person in such manner as to become subject to workrrisn's compeAsation_laws-of California." Contractdi s hiring or sub <br /> contracting signature <br /> certifies the following: 1 certify that in the performance of the work for which this permit isassued;i shall employ persons subiect to workman's compansa- <br /> tion laws of California." <br /> b The applicant must call fall r wired ins <br /> pections. Complete drawing on reverse side.1-4 Y = <br /> 'Signed X. Gr �l �� <br /> r Date:''y- - <br /> OR DEPARTMENT USE;ONLY <br /> Application Accepted by <br /> Date / Area ' <br /> Pit or Grout inspection by Date - Fina! Inspb'ction by { <br /> Date F <br /> Additional Comments: _ # <br /> Applicant - Return all copies to: San'Joaquin.County Public-Health <br /> i Services, Environmental Health Permit/Services <br /> t 1601 E. HazeTton'.Ave., P 0 Bax 2009, Stockton, CA 95201 <br /> FEE CK t <br /> _ INFO AMOUNT DUE AMOUNT REMITTED, ASH RECEIVED BY DATE PERMIT'NO. <br /> EH 13 2 R EV.f i r5 51 SIL.. /r J ' "x +' ti' - - �r .,.— <br /> EH 14,29 C {�/� !vim 14 , <br /> " I <br /> 4 <br />